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The problem of irregular menstruation
THE
PROBLEM
OF IRREOULAR
MENSTRUATION”
T
HE ~~c~m~wx of menstrual irregularities has long been held an important symptom in the study of gynecologic disease. This conception was based on t,he assumption t,hat t,he ~nrnses occur at regularly stated int,ervalx in t,he grea.t majority of individuals, and t,hat any deviation from this st,andard is evidence of a pathologic condition. There is, however. good reason to doubt the traditional belief that menstruation does occur regularly. and from this standpoint it. is neeessary to inquire further into the circumstances under which irregularities are of significance ilS a symptom of disease, The standard textbooks demonstrate a very general agreement on this fundamental yuest,ion. It, is statetl t,hat approximately 70 per cent of all patient,s bave regular menstruation of twenty-right or thirty days ’ duration, and that the balance present &her xbort,mrd or lengthened cycles. It is also clainletl that patients may be proupecl int,o specific categories accordin, ty to the length of the int.ervals! SLY as twenty-eight-day types, twenty-one-day types, t,hirty-day types, while it has been advanced that tbr total length of cycles in days is usually some multiple of seven, such as ‘28, 34. 35, &ct. B recent textbook of obstetrics even makes the statement that not only do t,he majority of women menstruate t~ery twenty-eight, days, but during the time of t,lie new moon. These assertions arc invariably based on statistical st,utlies made of the xt,atements of patients? the majority of whom undoubtedly make no effort to keel) accurate records of their menstrual prriods. From the standpoint, of scientific accuracy these liist,ories are of no value, and unfortunat,rly there have been but few at,tempts to study t,he question by means of carefully planned records, Three snch studies have been reported, one by Post,& in 1889, we by King” in 1926, and one by CTeist.”in 1930. and in each case it was clearly demonstrated that menstrual cycles not only in different individuals but in the same individual, vary tremendously in their duration. It, would seem, however, that t,raclitional beliefs and Innar superstitions have had a stronger hold on the profession t,han thrse valuable scientific contributions. The problem is one of such fundamental importance that an extensive investigation to determine the length of successive menstrual ‘Read Angeles,
nt a meeting of the Pacitic Calif., December 9. 1932.
Coast 642
Society
of Obstetrics
and Gynecology.
LOS
FLUHMANN
:
IRREGULAR
643
MENSTRUATION
cycles in a group of healthy young women was recently conducted with the assistance of Dr. Ethel D. Owen and the cooperation of the Stanford School of Nursing (FluhmanrP). A large group of nurses were given small calendars on which t,he dates of their menses were recorded, and from this the cycles were estimated as periods extending from the first day of a menstrual flow to the next. Every precaution was taken to eliminate any possible pathologic state or abnormal condition due t,o life in an institution, and finally 76 records were accepted as the basis for this analysis. Each individual was observed for periods varying from six to thirteen months, and a tot,al of 747 cycles was available for study. An analysis of the 747 cycles shows very clearly the great variability in their length. The range is from 11 to over 144 days, although 97 per cent of instances were grouped between eighteen and forty-two days. The most frequent cycle was of twenty-nine days with 73 eases, while the mean was of 30.4 days. A study variability
of in
the individual cases is still more impressive the lengths of successive cycles. No instance
as regards
the
great
of absolute regularity was noted. However, by giving a very loose interpretation to the term “regular” and considering as such the cases where all but one or two cycles fell within a five-day period, 28, or one-third, could be placed in this category. Of these, only 9 had cycles which fell within twenty-six to thirty days, while in 6 there was a tendency for the cycles to be shorter, and in 13 to bc of longer duration. In 48, or two-thirds, of the cases the cycles were very irregular. Although in 16 the menses were considered as of the “irregular delayed” type, it is notcworthy that only 4 fell in the “irregular too frequent” group. On the other hand, the largest group of the series, 28 cases, showed a. tremendous variability in the lengths of the cycles, some at times being very short (for example, eleven days) and others very long (for example, seventy-eight days).
However revolutionary these results may seem to be, t,hey are in keeping both with those of Foster and of King, and likewise with those of a third unpublished study conducted in Baltimore, Md., by Dr. Josephine Ball (Hartman”). It would seem that our future interpretation of menstrual irregularities must be approached with the conception that such irregularities are more frequent in normal individuals than so-called regular cycles. POLYMENORRHEA
The least frequent type of menstrual cycle noted in the Stanford investigation was that of shortened duration, since there were only 6 (7.8 per cent) in the “regular too frequent” and 4 (5.2 per cent) in the “irregular too frequent” group. This is of interest not only because this irregularity is of considerable importance as a symptom of disease, but also because these figures correspond closely to a number of other statistics on normal menstruation which were based on patients’ statements. It seems quite logical that a ‘woman
644
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
OYNECOLOGiY
who menstruates at intervals of t,wo or three weeks would much more readily have her attention directed to this phenomenon than one in whom the periods are further apart. In a previous communication (B’luhmann”) the mechanism by which polymenorrhea as a.n abnormal condition may be brought about, was discussed. It was pointed out,. in the first place, that the patients may have a hyperplasia of the endometrium, a condition characterized by a failure of ovulation with conseyuent lack of corpus luteum formation and an excessive production of the ovarian follicular hormone (“hyperestrinism”). In 8 out, of $5 patient,s with this condition cyclical bleeding was noted at intervals shorter tShan four weeks (Pluhmann’). The second possibility, which was advanced by Schrneder,” is that the menstrual cycle is shortened because of an injury or inherent weakness of the ovary so that there is a prcma.ture disintegration of the corpus luteum wit,11 a resultant early appearance of menstruat.ion. This is apparently the explanaCion for 111~:occurrence of too frequent menses in patients with pelvic inflammatory disease (E’luhmann”). The third possibility is based on the assumption that there is a speeding up of all t,he events of the menstrual cyclrl. and it, was intimated t,hat this may be due to a primary ovrractivit; of the antrrior hypophysis. A fourth theoretical possibility may be advanccrl although it representas an unusual condition, namely. that some worn en may have a slight flow at the time of ovulation such as occurs in cert,ain animals. There thus appears frequent cyclical bleeding bnt. only every second period can be considered as true menstruation. In an analysis of abnormal uterine hemorrhage in 507 gynecologic patient,s (Fluhmann and Morse’“) it, was observed that t.his bleeding was cyclical and occurred at int.ervals shorter than four weeks in 59 cases. In all but 9 of these, an organic lesion such as pelvic inflammatory disease, fibromyoma ut,eri, or Ilyperplasia. oi’ the entlometrium, was present, and in 34 of the 59 profuse periods wt’rt complained of in addition to the frequency of occurrence. It, has seemed importa.nl, therefore, to review these histories and analyze t,his symptom in mortl detail. It was then found that in only 8 instances had t,he menses been too frequent since their onset at puberty a.nd no recent change had been observed. In 4 cases the menses had always btlen frequent, but some additional abnormality, such as a, more profuse flow or shortening of the cycle, had supervened! while in 5 cases this information could not be obtained from the hist,ory. On the ot2ter hand, the shortening of the cycle in 42 of the 59 cases was a symptom which had appeared secondarily a few months or pears before the r)atient, reported for treat,ment. It would seem, therefore, that, polymenorrhea must still be eonsidered as an important symptom directing attention to pelvic disease. It is, however, of the utmost consequence to remember that it only has
PLUHMANN
:
IRREGULAR
MENSTRUATION
645
full significance when it appears as a change from a previous rhythm or when it is accompanied by an increase in t,he amount of blood loss. The occurrence of menses at more frequent intervals than four weeks, especially when persisting from the time of puberty, may be an essentially normal phenomenon, and when unassociated with demonstrable pelvic disease or harmful blood loss, is not per se an indication for treatment. DELAYED
MENSES
The significance of irregular delayed menses becomes still more difficult to interpret when the fact that two-thirds of normal women have prolonged cycles is taken into consideration, This symptom has been held an important indication of diminished ovarian activity and as a prominent factor in sterility, but it would seem that considerable doubt must be attached to statistics which are advanced to prove this contention since accurate figures for control series were not employed. The occurrence of irregular delayed menses is not incompatible with normal health, and the majority of these women not only have large families but do not necessarily develop more serious conditions subsequently. A review of the last 15 cases of irregular delayed menses in married women reporting for investigation shows that 9 had always had long menstrual cycles and of these 7 had borne full-term children. The two who had never become pregnant were young women of twenty-two and twenty-three respectively, so that they could hardly as yet be considered sterile. An analysis of the histories of 18 women with prolonged periods of amenorrhea, which must be considered as a serious complication, presents some interesting information on the relation of irregular delayed menses to this condition. In 10 of the patients there had always been irregular delayed menses, in 7 they had been considered as regular, while in one they were stated as being at first regular and later irregular. There is such a slight difference in the two groups, and in the normal series irregular delayed menses occurred so much more frequently than so-called regular, that one is inclined to believe that the existence of irregular delayed menses alone is not an important precursor of cessation of ovarian function. On the other hand, the occurrence of irregular delayed menses is undoubtedly associated with other features which indicate an abnormal condition. One of the most frequent concomitant symptoms is that of scanty flow, and it would seem that this is a very important feature. In the Stanford series, 823 menstrual periods were analyzed and it was found that under normal conditions the average duration of the hemorrhage is 4.6 days, while in the vast majority of instances it varies from three to seven days. It also seemed definite that the length of the menstrual cycle in normal individuals has no influence on the duration of the flow which remains a much more constant fac-
tot-. The occurrence of an)* tnarktd t~hatrge ilt thr Ivugtll of the mwstrual periods or in the amount. of blood loss is apparently a more sig-
nificant, finding indicating an i\bnol~mirl wntlitiw! tllilll any irregularity in the length of the cycales. Among other important findings which may be associated with irregular delayed menses in addition to scantiness of the flow, are obesity, hypertrichosis, vasomotor disturbances and diminished basal metabolic rate. It cannot, be denied t’hat these patient,s form an important endocrinologic group which is sorely in nerd of careful investigation and the development of aclrcluate treat,ment. The finding of irregular delayed menses in such patients, however. may not be as significant as it, has been niaint.ainwl, since all the associated symptoms mentioned above may be present in wwlt’n who zhim that their periods occur regularly every month. It \\w111cl S1'PIII that il propwssive condition where the e\-cles brcon~r succcssivrl~* longer and the flow gradually less, is a much more significant sign t,han the mere fac:f that the patient’s menses have been irregularly delayed since pubertyv.
Eecent, investigat,ion suggests that the length of succrssiva tnenstrual cycles in normal women is ~~haracterized by a marked irrepularity in at, least two-thirds of instances. The occurrence of irregular mrnstrual cycles in t,he absence of demonstrable pelvic disease should not be considered as an abnormal finding requiring treatment, unless (1 j it represents a change from a previously established rhythm. (2) it is accompanied by a marked increase (Jr decrease in blood loss, or (:3) it is associat,ed with conwmitant sympt,oms pointin, 11~ i o aII rndocrinologic disturbance.
(1) Foster, E. F.: N. Y. Med. .J. 49: 610, 1889. (Sj liiny, J. J,.: Cont. to E:mbryol. 18: 79, 1906. (3) Grist, S. If. : Ant. J. OBST. & UYNEC. 20: 320, 1930. (4) FZztlamu#~, C. P. : To be published. (“1 Hnsfmafn, C. G. : Personal communication. (6) Fhhtnaa~~, C. F.: Endocrinology 15: 177, 1931. (7) Idem: Surg. Gynee. Obst. 52: 1051, 1931. (8) Sclwosde~, Ic.: I)er mensuelle Genitalzyklus des Weibes und seine Stiirungen, in Veit,-Stocckel: Hsndbuch der Gynaekologie, Munich, 5. I?. Bergmann 1: part 2, 1928. (9) Flulwmnn, C. P.: J. A. M. A. 97: 694, 1931. (10) Fluhmann, C. P., and &low, D. I..: Au. J. Ons’r. & GY?;EC. 21: 455, 1931.
PROBLEM
OF IRREOULAR
MENSTRUATION”
T
HE ~~c~m~wx of menstrual irregularities has long been held an important symptom in the study of gynecologic disease. This conception was based on t,he assumption t,hat t,he ~nrnses occur at regularly stated int,ervalx in t,he grea.t majority of individuals, and t,hat any deviation from this st,andard is evidence of a pathologic condition. There is, however. good reason to doubt the traditional belief that menstruation does occur regularly. and from this standpoint it. is neeessary to inquire further into the circumstances under which irregularities are of significance ilS a symptom of disease, The standard textbooks demonstrate a very general agreement on this fundamental yuest,ion. It, is statetl t,hat approximately 70 per cent of all patient,s bave regular menstruation of twenty-right or thirty days ’ duration, and that the balance present &her xbort,mrd or lengthened cycles. It is also clainletl that patients may be proupecl int,o specific categories accordin, ty to the length of the int.ervals! SLY as twenty-eight-day types, twenty-one-day types, t,hirty-day types, while it has been advanced that tbr total length of cycles in days is usually some multiple of seven, such as ‘28, 34. 35, &ct. B recent textbook of obstetrics even makes the statement that not only do t,he majority of women menstruate t~ery twenty-eight, days, but during the time of t,lie new moon. These assertions arc invariably based on statistical st,utlies made of the xt,atements of patients? the majority of whom undoubtedly make no effort to keel) accurate records of their menstrual prriods. From the standpoint, of scientific accuracy these liist,ories are of no value, and unfortunat,rly there have been but few at,tempts to study t,he question by means of carefully planned records, Three snch studies have been reported, one by Post,& in 1889, we by King” in 1926, and one by CTeist.”in 1930. and in each case it was clearly demonstrated that menstrual cycles not only in different individuals but in the same individual, vary tremendously in their duration. It, would seem, however, that t,raclitional beliefs and Innar superstitions have had a stronger hold on the profession t,han thrse valuable scientific contributions. The problem is one of such fundamental importance that an extensive investigation to determine the length of successive menstrual ‘Read Angeles,
nt a meeting of the Pacitic Calif., December 9. 1932.
Coast 642
Society
of Obstetrics
and Gynecology.
LOS
FLUHMANN
:
IRREGULAR
643
MENSTRUATION
cycles in a group of healthy young women was recently conducted with the assistance of Dr. Ethel D. Owen and the cooperation of the Stanford School of Nursing (FluhmanrP). A large group of nurses were given small calendars on which t,he dates of their menses were recorded, and from this the cycles were estimated as periods extending from the first day of a menstrual flow to the next. Every precaution was taken to eliminate any possible pathologic state or abnormal condition due t,o life in an institution, and finally 76 records were accepted as the basis for this analysis. Each individual was observed for periods varying from six to thirteen months, and a tot,al of 747 cycles was available for study. An analysis of the 747 cycles shows very clearly the great variability in their length. The range is from 11 to over 144 days, although 97 per cent of instances were grouped between eighteen and forty-two days. The most frequent cycle was of twenty-nine days with 73 eases, while the mean was of 30.4 days. A study variability
of in
the individual cases is still more impressive the lengths of successive cycles. No instance
as regards
the
great
of absolute regularity was noted. However, by giving a very loose interpretation to the term “regular” and considering as such the cases where all but one or two cycles fell within a five-day period, 28, or one-third, could be placed in this category. Of these, only 9 had cycles which fell within twenty-six to thirty days, while in 6 there was a tendency for the cycles to be shorter, and in 13 to bc of longer duration. In 48, or two-thirds, of the cases the cycles were very irregular. Although in 16 the menses were considered as of the “irregular delayed” type, it is notcworthy that only 4 fell in the “irregular too frequent” group. On the other hand, the largest group of the series, 28 cases, showed a. tremendous variability in the lengths of the cycles, some at times being very short (for example, eleven days) and others very long (for example, seventy-eight days).
However revolutionary these results may seem to be, t,hey are in keeping both with those of Foster and of King, and likewise with those of a third unpublished study conducted in Baltimore, Md., by Dr. Josephine Ball (Hartman”). It would seem that our future interpretation of menstrual irregularities must be approached with the conception that such irregularities are more frequent in normal individuals than so-called regular cycles. POLYMENORRHEA
The least frequent type of menstrual cycle noted in the Stanford investigation was that of shortened duration, since there were only 6 (7.8 per cent) in the “regular too frequent” and 4 (5.2 per cent) in the “irregular too frequent” group. This is of interest not only because this irregularity is of considerable importance as a symptom of disease, but also because these figures correspond closely to a number of other statistics on normal menstruation which were based on patients’ statements. It seems quite logical that a ‘woman
644
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
OYNECOLOGiY
who menstruates at intervals of t,wo or three weeks would much more readily have her attention directed to this phenomenon than one in whom the periods are further apart. In a previous communication (B’luhmann”) the mechanism by which polymenorrhea as a.n abnormal condition may be brought about, was discussed. It was pointed out,. in the first place, that the patients may have a hyperplasia of the endometrium, a condition characterized by a failure of ovulation with conseyuent lack of corpus luteum formation and an excessive production of the ovarian follicular hormone (“hyperestrinism”). In 8 out, of $5 patient,s with this condition cyclical bleeding was noted at intervals shorter tShan four weeks (Pluhmann’). The second possibility, which was advanced by Schrneder,” is that the menstrual cycle is shortened because of an injury or inherent weakness of the ovary so that there is a prcma.ture disintegration of the corpus luteum wit,11 a resultant early appearance of menstruat.ion. This is apparently the explanaCion for 111~:occurrence of too frequent menses in patients with pelvic inflammatory disease (E’luhmann”). The third possibility is based on the assumption that there is a speeding up of all t,he events of the menstrual cyclrl. and it, was intimated t,hat this may be due to a primary ovrractivit; of the antrrior hypophysis. A fourth theoretical possibility may be advanccrl although it representas an unusual condition, namely. that some worn en may have a slight flow at the time of ovulation such as occurs in cert,ain animals. There thus appears frequent cyclical bleeding bnt. only every second period can be considered as true menstruation. In an analysis of abnormal uterine hemorrhage in 507 gynecologic patient,s (Fluhmann and Morse’“) it, was observed that t.his bleeding was cyclical and occurred at int.ervals shorter than four weeks in 59 cases. In all but 9 of these, an organic lesion such as pelvic inflammatory disease, fibromyoma ut,eri, or Ilyperplasia. oi’ the entlometrium, was present, and in 34 of the 59 profuse periods wt’rt complained of in addition to the frequency of occurrence. It, has seemed importa.nl, therefore, to review these histories and analyze t,his symptom in mortl detail. It was then found that in only 8 instances had t,he menses been too frequent since their onset at puberty a.nd no recent change had been observed. In 4 cases the menses had always btlen frequent, but some additional abnormality, such as a, more profuse flow or shortening of the cycle, had supervened! while in 5 cases this information could not be obtained from the hist,ory. On the ot2ter hand, the shortening of the cycle in 42 of the 59 cases was a symptom which had appeared secondarily a few months or pears before the r)atient, reported for treat,ment. It would seem, therefore, that, polymenorrhea must still be eonsidered as an important symptom directing attention to pelvic disease. It is, however, of the utmost consequence to remember that it only has
PLUHMANN
:
IRREGULAR
MENSTRUATION
645
full significance when it appears as a change from a previous rhythm or when it is accompanied by an increase in t,he amount of blood loss. The occurrence of menses at more frequent intervals than four weeks, especially when persisting from the time of puberty, may be an essentially normal phenomenon, and when unassociated with demonstrable pelvic disease or harmful blood loss, is not per se an indication for treatment. DELAYED
MENSES
The significance of irregular delayed menses becomes still more difficult to interpret when the fact that two-thirds of normal women have prolonged cycles is taken into consideration, This symptom has been held an important indication of diminished ovarian activity and as a prominent factor in sterility, but it would seem that considerable doubt must be attached to statistics which are advanced to prove this contention since accurate figures for control series were not employed. The occurrence of irregular delayed menses is not incompatible with normal health, and the majority of these women not only have large families but do not necessarily develop more serious conditions subsequently. A review of the last 15 cases of irregular delayed menses in married women reporting for investigation shows that 9 had always had long menstrual cycles and of these 7 had borne full-term children. The two who had never become pregnant were young women of twenty-two and twenty-three respectively, so that they could hardly as yet be considered sterile. An analysis of the histories of 18 women with prolonged periods of amenorrhea, which must be considered as a serious complication, presents some interesting information on the relation of irregular delayed menses to this condition. In 10 of the patients there had always been irregular delayed menses, in 7 they had been considered as regular, while in one they were stated as being at first regular and later irregular. There is such a slight difference in the two groups, and in the normal series irregular delayed menses occurred so much more frequently than so-called regular, that one is inclined to believe that the existence of irregular delayed menses alone is not an important precursor of cessation of ovarian function. On the other hand, the occurrence of irregular delayed menses is undoubtedly associated with other features which indicate an abnormal condition. One of the most frequent concomitant symptoms is that of scanty flow, and it would seem that this is a very important feature. In the Stanford series, 823 menstrual periods were analyzed and it was found that under normal conditions the average duration of the hemorrhage is 4.6 days, while in the vast majority of instances it varies from three to seven days. It also seemed definite that the length of the menstrual cycle in normal individuals has no influence on the duration of the flow which remains a much more constant fac-
tot-. The occurrence of an)* tnarktd t~hatrge ilt thr Ivugtll of the mwstrual periods or in the amount. of blood loss is apparently a more sig-
nificant, finding indicating an i\bnol~mirl wntlitiw! tllilll any irregularity in the length of the cycales. Among other important findings which may be associated with irregular delayed menses in addition to scantiness of the flow, are obesity, hypertrichosis, vasomotor disturbances and diminished basal metabolic rate. It cannot, be denied t’hat these patient,s form an important endocrinologic group which is sorely in nerd of careful investigation and the development of aclrcluate treat,ment. The finding of irregular delayed menses in such patients, however. may not be as significant as it, has been niaint.ainwl, since all the associated symptoms mentioned above may be present in wwlt’n who zhim that their periods occur regularly every month. It \\w111cl S1'PIII that il propwssive condition where the e\-cles brcon~r succcssivrl~* longer and the flow gradually less, is a much more significant sign t,han the mere fac:f that the patient’s menses have been irregularly delayed since pubertyv.
Eecent, investigat,ion suggests that the length of succrssiva tnenstrual cycles in normal women is ~~haracterized by a marked irrepularity in at, least two-thirds of instances. The occurrence of irregular mrnstrual cycles in t,he absence of demonstrable pelvic disease should not be considered as an abnormal finding requiring treatment, unless (1 j it represents a change from a previously established rhythm. (2) it is accompanied by a marked increase (Jr decrease in blood loss, or (:3) it is associat,ed with conwmitant sympt,oms pointin, 11~ i o aII rndocrinologic disturbance.
(1) Foster, E. F.: N. Y. Med. .J. 49: 610, 1889. (Sj liiny, J. J,.: Cont. to E:mbryol. 18: 79, 1906. (3) Grist, S. If. : Ant. J. OBST. & UYNEC. 20: 320, 1930. (4) FZztlamu#~, C. P. : To be published. (“1 Hnsfmafn, C. G. : Personal communication. (6) Fhhtnaa~~, C. F.: Endocrinology 15: 177, 1931. (7) Idem: Surg. Gynee. Obst. 52: 1051, 1931. (8) Sclwosde~, Ic.: I)er mensuelle Genitalzyklus des Weibes und seine Stiirungen, in Veit,-Stocckel: Hsndbuch der Gynaekologie, Munich, 5. I?. Bergmann 1: part 2, 1928. (9) Flulwmnn, C. P.: J. A. M. A. 97: 694, 1931. (10) Fluhmann, C. P., and &low, D. I..: Au. J. Ons’r. & GY?;EC. 21: 455, 1931.